The nurse is caring for a client who sustained a compound fracture of the right tibia/fibula postoperative ORIF (open reduction internal fixation). A complete assessment of the affected extremity would include:

Capillary refill, color of extremity.

Pedal pulses.

ACE wrap, Velcro boot, and hanging weights.

Pin sites.

Temperature, sensation, and movement of toes.

Answer and Explanation

Correct Answer : A,B,D,E

Choice a reason:
Assessing capillary refill and the color of the extremity is essential for determining the vascular status of the limb. A normal capillary refill time is less than 2 seconds and indicates good blood flow. The color should be consistent with the rest of the body, without pallor or cyanosis, which could indicate compromised circulation.

Choice b reason:
Checking pedal pulses is another critical aspect of assessing vascular integrity. The presence of strong and equal pulses in both feet suggests that the blood supply to the lower extremities is not compromised.

Choice c reason:
While the ACE wrap and Velcro boot are part of the postoperative management to provide support and protection to the affected limb, and hanging weights might be used for traction, these are not part of the physiological assessment of the extremity.

Choice d reason:
Monitoring pin sites for signs of infection, such as redness, swelling, or discharge, is crucial in a client with ORIF. Infection can lead to complications that may affect the healing process and the integrity of the fixation.

Choice e reason:
Evaluating the temperature, sensation, and movement of toes helps in assessing for potential nerve damage or compartment syndrome. Any changes in these parameters should be reported immediately as they may signify serious complications.

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Correct Answer is C

Explanation

Choice A Reason
While coronary artery spasm can cause chest pain, it is not the typical cause of unstable angina. Unstable angina is generally due to atherosclerotic heart disease, where plaque buildup in the coronary arteries restricts blood flow. This statement does not fully reflect an understanding of the condition.

Choice B Reason
Beta blockers are often prescribed to manage angina as they reduce the heart's workload and oxygen demand. However, they do not always prevent angina pain, especially in the case of unstable angina, which can occur unpredictably and not just during exertion. This statement shows partial understanding but lacks the urgency associated with unstable angina.

Choice C Reason
Seeking immediate medical attention when experiencing angina pain is crucial, especially in the case of unstable angina, which can signal an impending heart attack. This statement indicates that the client understands the seriousness of their condition and the need for prompt action.

Choice D Reason
While rest can help alleviate stable angina pain, unstable angina is less predictable and may not be relieved by rest. This type of angina requires medical evaluation to prevent more serious complications, such as myocardial infarction. This statement does not convey an adequate understanding of the condition.

A. "You will need to take this medication with food from now on." B. "You should avoid dangerous activities because of the side effects you are experiencing." C. "The medication is usually prescribed for a short time, and the side effects may go away." D. "You can use sugarless gum or candy to relieve some of those symptoms."

Correct Answer is B

Explanation

Choice A Reason
Taking alprazolam with food may help with some gastrointestinal side effects but does not address the client's concerns about dizziness and light-headedness. While it is a practical suggestion, it is not the priority response when the client is experiencing symptoms that could affect their safety¹.

Choice B Reason
The priority for the nurse is to ensure the client's safety. Dizziness and light-headedness can increase the risk of falls or accidents, especially when performing tasks that require alertness, such as driving or operating machinery. Therefore, advising the client to avoid dangerous activities is the most immediate and appropriate response¹.

Choice C Reason
While it is true that alprazolam is often prescribed for short-term use and some side effects may diminish over time, this does not provide the client with a solution to their current symptoms. The nurse should address the client's immediate concerns and ensure their safety before discussing the duration of medication use¹.

Choice D Reason
Using sugarless gum or candy can help with dry mouth, which is a common side effect of alprazolam. However, this advice does not address the more serious side effects of dizziness and light-headedness that the client is experiencing. Therefore, it is not the priority response but can be included as additional advice¹.

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The nurse is caring for a client who sustained a compound fracture of the right tibia/fibula postoperative ORIF (open reduction internal fixation). A complete assessment of the affected extremity would include:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which statement, made by the client diagnosed with unstable angina, reflects an understanding of the nurse's discharge teaching?

Correct Answer is C

Explanation

Two months after beginning drug therapy with alprazolam, a client states, "I feel much better, but I can't believe how dizzy and light-headed I get, and sometimes my mouth feels dry." Which would be the priority response by the nurse?

Correct Answer is B

Explanation

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